(1058) ECG-Guided CVC Placement With Post-Procedure Ultrasound

Introduction: Insertion of internal jugular (IJ) and subclavian (SC) central venous catheters (CVC) conventionally require a confirmatory chest x-ray (CXR) to assess catheter tip position and exclude pneumothorax. Electrocardiogram (ECG) guided CVC placement utilizes p-wave morphology to localize tip location. Correct tip position for IJ and SC CVCs is at the cavo-atrial junction. Excessive depth can stimulate the right atrium, and promote arrhythmia; accordingly catheter retraction may be required. ECG-guided CVC placement leads to correct positioning in a high proportion of patients. Lung ultrasound has superior efficiency than CXR in diagnosing pneumothorax.

Methods: A prospective observational study was conducted to assess the combination of ECG guidance to assess catheter tip location and bedside ultrasonography to detect pneumothorax following CVC placement. Subsequent CXR was completed in accordance with regional practice; tip location was identified by the interpreting radiologist. Patients without sinus rhythm were excluded. Data collection was completed using a protocolized approach.

Results: A total of 27 patients underwent ECG-guided CVC placement with post-procedure lung ultrasound over a 16 month period. 70% of patients were male, mean BMI was 29.1 (6.6), and 74% of patients were being treated with mechanical ventilation. Location of insertion was the right IJ in 48%, left IJ in 33%, right SC in 7%, and left SC in 11%. Mean insertion depth and number of attempts were 17.5 (1.5) cm and 1.3 (0.5) respectively. Pre-procedural lung ultrasound showed ipsilateral preservation of lung-sliding in all but one patient (96%);post-procedural findings were identical. Confirmatory CXR showed tip location in the superior vena cava in 81% of patients, cavoatrial junction in 15% and brachiocephalic vein in 4%; right atrial location or pneumothorax were not identified on any CXR.

Conclusions: In a small cohort, ECG-guided CVC placement in combination with bedside lung ultrasound prevented excessively deep CVC insertion and accurately ruled out pneumothorax in patients with preserved pre-procedure lung sliding. Further study of these modalities is warranted to determine if post procedure chest radiograph can be eliminated improving cost, safety and timeliness of CVC use.